Chapter 2 Enhancing Childhood Development in Children with Autism

Transcription

1 Chapter 2 Enhancing Childhood Development in Children with Autism Keywords Autism Asperger s syndrome Speech delay Early intervention Pervasive developmental disorder Autism Interaction Autism Communication Autism spectrum disorder (ASD) refers to a group of neuro-developmental disorders that in fl uence social interaction, communication, and cognitive development [ 1 3 ]. Autism is a spectrum disorder, with large variability in the presenting symptoms and their severity. Currently there is no cure for Autism or ASD; however, children diagnosed with ASD are capable of progressing developmentally and acquiring new skills in language and social interaction. Early surveillance and screening for ASD is essential to ensure early detection and hence early referral for initiation of intervention programs and thus achieve a better outcome [ 1, 4 ]. According to the DSM-IV-TR, disorders such as Asperger Syndrome, Childhood Disintegrative Disease, Rett s Disorder, and Pervasive Developmental Disorder-Not Otherwise Speci fi ed (PDD-NOS) are placed at one end of the spectrum, while others such as Autism, Classic Autism, and Kanner Autism are placed at the other end [ 5 ]. Children and adults with autism often show some intellectual disabilities [ 6 ]. D. Sinno et al., Enhancing Early Child Development: A Handbook for Clinicians, DOI / _2, Springer Science+Business Media, LLC

2 18 2 Enhancing Childhood Development in Children with Autism Manifestations of social and communication dif fi culties become clear before the age of 3 years [ 1 3, 6 ]. Issues in social development include unusual or delayed responses to social stimuli as well as low levels of social engagement and interest [ 1 3, 6, 7 ]. Additionally, autistic children exhibit problems and delays in language and selfcare skills and often lack attention. Speech may be severely delayed or entirely absent in some cases of autism [ 1 3, 6, 7 ]. Routine behaviors and habits such as fi nger gazing, walking on toes, and hand gestures are noticeable among these children [ 1 3, 6, 7 ]. Social Defects Children with autism are sometimes withdrawn and comfortable with being alone and tend to avoid eye contact and attracting attention. They also exhibit dif fi culties in responding to gestures, vocalizations, and in emotional situations. They have problems in social interactions with other children through play and educational activities [ 1 ]. These social de fi cits and manifestations are often not clearly apparent at an early age and often overlooked, causing a delay in diagnosis of autism [ 1 3, 6, 7 ]. Table 1 outlines slight differences in social and behavioral development of children that may often be overlooked [ 1 ].

3 Social Defects 19 Age Typically developing children Children with autism spectrum disorders months Begin to follow a point May not follow a point, even when one tries repeatedly to call their names in a loud voice or uses physical prompts months Point to request an object Make efforts by opening and closing their hand while it is raised in the direction of the desired item but without any back and forth looking between it and the caregiver months Begin to point, to comment on or share an interesting object By 4 years of age Begin to have some sense of other s mental state Novel situations Look to their mothers for an indication of delight, anger, or fear in facial expression. They may mimic hers, although they may not fully understand the situation Fail to point, to comment at age-appropriate times, and when they do, they are less likely to show positive affect and connectedness during the act Have dif fi culties with empathy, sharing, and comforting Engage in less imitation

4 20 2 Enhancing Childhood Development in Children with Autism Speech Deficits Speech de fi cits may also be recognized at an early age given certain signs that may predict speech or language problems. Early on, the child lacks appropriate gaze in general and speci fi cally does not exhibit expressions with his/her gaze. At approximately 6 months, the child vocalizes independently of his parents instead of mimicking the parents vocalizations. Moreover, there is a general lack of response to and recognition of the primary caregiver s voice, even in cases where the child s name is called. At the age of 9 months, the child still exhibits a delay in babbling and using gestures such as waving or pointing. Moreover, the child does not use expressions or show interest in the expressions or statements of others [ 1 ]. Communication with Autistic Children A variety of interventions have been developed over the years for enhancing development and communication of children with autism [8 ]. For the purpose of this manual, the focus will be on enhancing communication with autistic children through daily activities that can be applied at home. Principles from Daily Life Therapy and the Picture Exchange Communication System (PECS) will be applied to improve communication, imitation, and self-care skills among these children [ 4, 9, 10 ]. Daily Life Therapy This therapy focuses on principles that encourage the establishment of a rhythm or routine in daily life [ 4, 10 ]. Its effectiveness lies in the fact that children with autism are often engaged in routine behaviors [1 3, 6, 7 ] and it builds upon that characteristic to teach them new skills. For example, one can repeat certain words by putting it in simple sentences and encouraging the child to speak by asking him simple questions (Fig. 2.1 ).

5 Communication with Autistic Children 21 Train, Look, there s the train, Train goes choo choo. What are you playing with,a train? Train Fig. 2.1 Mother encouraging child to speak by asking him simple questions Picture Exchange Communication System PECS focuses on improving communication and language skills of children with autism within their social environments. It highlights the use of pictures as a communication technique to help them better visualize what they want or need [ 9 ] (Fig. 2.2 ).

6 22 2 Enhancing Childhood Development in Children with Autism Fig. 2.2 Use of pictures to communicate General Tips for Daily Activities Following are advice the clinicians may give mothers and caregivers of children with autism in order to optimize various aspects of their development. Eating Tips Encourage the child by inviting him to eat through singing (Fig. 2.3 ). Encourage the child to communicate by speech. For example, prompt him to ask for more food by serving him with a small amount initially, forgetting to put a certain type so that he would notice it and ask for it (Fig. 2.4 ) or giving him the opposite of what he asked for to stimulate him to ask again for what he wants (Fig. 2.5 ). Name the types of food by pointing at them, allow the child to point at the food that he wants (Fig. 2.6a ). Show the child a list of two

7 General Tips for Daily Activities 23 I am hungry let s go eat!! Fig. 2.3 Tips to encourage eating or three food choices and ask him to point out his choice. The list may be made up of pictures (Fig. 2.6b ). Repeat a certain sentence or song after every meal (Fig. 2.7 ). Dressing Tips Encourage the child to participate in getting dressed by directing him to extend his arms or legs (Fig. 2.8 ). Accompany the actions with words and encourage him to repeat them (Fig. 2.9 ). Encourage the child to fi nish getting dressed on his own and praise him when he is done: Good, you did it yourself (Fig ). Accompany the child in choosing his clothes from the closet (Fig ). Arrange the child s clothes on the bed in an organized manner in order for him to choose his out fi t (Fig ). Show the child pictures that explain the process

8 24 2 Enhancing Childhood Development in Children with Autism Are you still hungry? Do you want more fries? I want! Who wants fries? Fig. 2.4 Tips to prompt child to communicate at the table of getting dressed while giving him directions if possible (Fig ). Bathing Tips Encourage the child to take a bath by singing or by pointing to things or repeating the same words every time (Fig ). Encourage the

9 a More! b String beans! c String beans! Fig. 2.5 Tips to prompt child to communicate his needs

10 26 2 Enhancing Childhood Development in Children with Autism a Meat balls String beans Broccoli Fries b Fig. 2.6 (a) Encourage child to point at the food he wants; (b) Use picture-list of different food items

11 Entertainment 27 Thank you for good food Thank you for good food Fig. 2.7 Communication through singing child to participate in giving things (Fig ). Give the child toys that fl oat or that can be fi lled with water to play with (Fig ). Teach the child about body organs and senses repeat simple words slowly but in an expressive way (Fig ). Keep your position face to face with the child during bathing (Fig ). Allow the child to feel all the material to be used in bathing (Fig ). Show the child stages of bathing using pictures and/or words (Fig ). Repeat the same way of fi nishing the bathing each time. For example, put some calm music or repeat a certain song (Fig ). Entertainment Entertainment is divided into four categories: 1. Social playing 2. Singing 3. Reading 4. Playing with toys

12 28 2 Enhancing Childhood Development in Children with Autism Come get dressed Fig. 2.8 Tips for promoting child participation in getting dressed

13 Now we put our hands out Hands out Fig. 2.9 Dressing-up aid Good, you did it yourself. Fig Tips to encourage autonomy

14 30 2 Enhancing Childhood Development in Children with Autism Fig Choosing own cloth Social playing This kind of playing requires from the child to communicate, to participate, and to react with others. It is organized and it is easy to predict what will happen. It involves feelings that relax the child: actions, words, and repetitive sounds. It is interesting and enjoyable. It can include: peekaboo, hide-and-seek, horse riding (on parent s leg) (Fig ), swinging, etc.

15 Entertainment 31 Fig Arrange clothes on bed to help child choose his out fi t Fig Use dolls to explain dressing process

16 We are going to take a bath! Fig Tips to encourage taking a bath a Give me the soap Fig (a) Involve child in bathing process

17 Entertainment 33 b This is soap! This is water! This is shampoo! What s that? Give me the shampoo Fig (b) Tips during bathing

18 34 2 Enhancing Childhood Development in Children with Autism Fig Make bath more enjoyable Stomach Fig Introduce child to body parts

19 Entertainment 35 Fig Interact with child during bath Preparation for the Activity Repeat what you say and do at the beginning of the activity, during, and at the end of the activity. During the Activity Give the child the opportunity to take roles (Fig ) and help him do this by getting involved in his interests and changing the way of play if necessary. For example, you are playing peekaboo with the child and you are hiding your face with a pillow and after some time of playing, the child goes to the curtains and hides behind them, you should continue the game by replacing the pillow with the curtains.

20 36 2 Enhancing Childhood Development in Children with Autism Sponge is soft Fig Make bathing environment familiar Singing One can use songs to communicate with the child. The song is a way that we can repeat everyday so that the child will get used to it and memorize its words. We advise accompanying the song with suitable movements and pictures to make memorization easier (Fig ). During the Activity Give the child the opportunity to take roles. Stop on words and gestures he likes and encourage him to continue.

21 Entertainment 37 Fig Teaching child the bathing process While singing, use few and simple words and stress on the main words. One has to use or create songs especially for the child and that meet his needs in order to help him ask for things, ask questions then answer, greet others, understand daily routine, and simple guidelines. Reading Reading is another way to strengthen communication with the child within enjoyable times that encourage interaction. As in songs, one has to repeat the same story several times.

22 38 2 Enhancing Childhood Development in Children with Autism We are finished, we smell nice Fig Finish bath with a song Reading the Right way Read the story in an enjoyable and exciting manner to draw his attention. Stress on what interests him. For example, if he points to a certain detail, one has to read the story while stressing this detail. [This is a way to communicate and to give information about what interests him.]

23 Entertainment 39 Fig Promoting social interaction Fig Playing and taking roles Simplify sentences. It is advisable not to read in a traditional way but rather to simplify sentences so that it would suit the child s abilities. Read for him in a lively and expressive manner.

24 40 2 Enhancing Childhood Development in Children with Autism Fig Promoting communication through songs If he wants to turn the pages, one has to participate with him doing this so that each one would turn one page of the book. Read slowly and repeat things. One has to stress certain words by showing the corresponding pictures so that the child would understand, memorize, and use them in a spontaneous manner. Give the child the opportunity to express his interests, one should not forget watching, slowing down, and explaining.

25 Entertainment 41 Playing with Toys Playing with toys is the easiest way to communicate with a child. One has to choose suitable toys such as visual environmental toys; toys with cause and result, sharing toys, building toys, blowing toys, toys with rules, symbolic toys, and physical play (Figs and 2.26 ). Playing Stage Ask the child to choose between two or more toys. Give him the toy he chose and watch him at a fi rst stage without directing him. Imitate the way he plays and share with him his way of playing. Fig Communicating through toys

26 42 2 Enhancing Childhood Development in Children with Autism We are putting blocks to make a building Fig Parent playing with her child stating out loud what they are doing If he feels bored, one should continue playing before moving to another play. Continuation is maintained by creating a new method of play and encouraging him to follow it. Take advantage of play time to enrich his language by simplifying words and sentences, stressing the main words, slowing down while talking, and pointing to what you are saying (Fig ). Finish the play in a routine way by a song for example (Fig ).

27 Daily Activities 43 a b Do you want me to open the box? Fig Parent encouraging child to play, ( a ) child looking not knowing what to do, ( b ) Parent inviting child by asking Daily Activities The daily activities shown through a series of pictures have the potential to decrease the child s anxiety (Fig ).

28 44 2 Enhancing Childhood Development in Children with Autism If you re happy and you know it clap your hands Fig Parent finishing an activity with a song How Does a Child with Autism Play? Playing is not easy for the child with autism. One can notice that he plays differently from what is expected since he chooses methods that suit him. The different ways used by those children depend on their way of communication with others and with the environment. A child with autism: 1. Does not play with toys, rather he is interested in chewing them. 2. Plays in an unusual way not the way expected from a child his age.

29 a b We are going to go to the playground Fig To decrease child s anxiety parent can use ( a ) a series of pictures or ( b ) one picture to explain what they are about to do

30 46 2 Enhancing Childhood Development in Children with Autism Fig Parent eliciting a child reaction by tickling 3. Plays in a particular way: he can play the right way with some games such as puzzles; he has his favorite games but cannot generalize the right way of playing to different games, and he can perform one task only in the game. 4. Can play in a well-built manner: he can specify a goal and work to achieve it. He can use toys to do something (e.g., pencils and papers for drawing). Children with limited communication skills should be able to participate in such activities. 5. Can play games with rules: he can take roles and play with others in a limited way. Children with limited communication skills like repeating the same playing method over and over. 6. Can play symbolic and imaginary games: Symbolic playing is pretending to do something imaginary such as drinking from an empty cup. All children with autism except those who do not communicate with others at all are capable of playing symbolic and imaginary games but in different ways. How to Play with a Child with Autism Playing with a child who has autism should go through the following stages:

31 Daily Activities 47 a We are going to play hide and seek and I m going to hide. b Fig ( a ) Parent telling the child What they are doing. ( b ) Parent hiding from child 1. Joining the child s interests: Paying attention to the way the child plays and joining him. 2. Explaining the child s words and actions: Dealing with everything that the child does as if it is directed to us to build a connection with him through playing.

32 48 2 Enhancing Childhood Development in Children with Autism This is a toy train Fig Parent showing a picture and naming the object a b OK, I will give you chocolates Fig ( a ) Child unable to reach chocolate on the table. ( b ) Child giving parent a picture of chocolate to express his need

33 Daily Activities 49 a Does Tom want to play? b Does Tom want to read? c Oh, Tom wants to play Fig ( a ) Mother asking if child wants to play using hand gestures. ( b ) Mother asking if child wants to read. ( c ) Child repeating the sign to express his needs and mother confirming her understanding 3. Imitating the child: Imitating the way the child plays helps him to interact with us and encourages him to imitate us. The goal is to transform single playing into interaction and participation. There should be insistence in order to reach this goal because the child will not be responsive from the fi rst time. 4. Entering into the child s world: Joining the child s play and insisting on that even if the child does not accept at fi rst. 5. Repeating what we do and say: When we start playing, we should repeat the game s name and this would create a routine that the

34 50 2 Enhancing Childhood Development in Children with Autism a Hello, daddy b Hello, daddy Fig Mother helping child mimic answering the phone

35 a My turn b My turn Fig Mother and child playing with ball and taking turns

36 52 2 Enhancing Childhood Development in Children with Autism a Who wants to play with the train? b Fig Mother plays and direct her child s play encouraging him to talk

37 Daily Activities 53 a Oh, you want the blocks b No. ball. Fig Mother encouraging her child to name toys he is pointing at

38 a I want to draw, give me a paper b Let s draw, give me a crayon Fig Mother encouraging child to follow commands and be an active player

39 Daily Activities 55 Fig Board games involving matching pictures are helpful for playing together Rick is angry Fig Mother alternating pictures displaying emotions child gets used to and pushes him to expect what will happen. During playing, should applaud for him after each stage or count 1, 2, 3 before each stage of the play. To help the child generalize what he learned with us, one should repeat the game and the way used with other people.

40 56 2 Enhancing Childhood Development in Children with Autism a What did you do in school today? Today I drew and I wrote b I drew Fig Mother encouraging child to communicate 6. Giving the child a chance to take roles: Planning for speci fi ed times to make the child take roles which means one should not continue playing but should stop to give the child the opportunity to take the initiative in speci fi ed times. Planning for a role for we want the child to take which means organizing the game in such a way to allow the child to participate in it. 7. Pointing to the child to help him take roles in the fi rst stage: The child will not take his role in a spontaneous way. One should help him by giving clear signs. These signs could be body hints, body and verbal examples, or verbal instructions. 8. Continuing the enjoyable activity: the child with autism gets bored easily and does not concentrate for a long time. Thus, one has to revive the game and continue with it as much as possible.

41 Daily Activities 57 a Hello Hello, how are you? b Hello, how are you? Fig Mother encouraging child to communicate

42 a Pencil break The pencil broke? b The pencil broke Fig Child showing his broken pencil trying to communicate

43 Daily Activities 59 a Oh, can I play with you? b Can I play with you? Fig Mother and child playing with toys

44 60 2 Enhancing Childhood Development in Children with Autism Types of toys a child with autism can play with 1. Toys with cause and result: these toys are the easiest because all autistic children are able to play with them whatever their method is. It is enough for the child to press on a button or open a box to hear a sound or to see something in front of him. 2. Visual environmental toys: These toys require recognizing easy shapes. It is enough for the child to look at them in order to understand them. 3. Building toys: These toys allow the child to build the shapes he wants. 4. Sharing toys: such as balls and keys. These toys encourage the child to share playing through giving toys to us then taking them back. The child will consider us as part of the game. 5. Blowing and music toys: These are easy toys and the best to teach the child how to play. They include balloons, soap blowing and music boxes. The goal is to create communication and interaction with the child. Through this play process one has to create dif fi culties the child cannot overcome on his own. This pushes him to ask for help to blow soap balloons for example. 6. Creativity playing: This type of playing stimulates children because it helps them experience new feelings. These include playing with sand, water, cotton, rice, papers, board, coloring pencils 7. Symbolic games: These are the toys that resemble real things such as cars and phones. They stimulate the child to do things similar to real life. 8. Physical playing: These games require physical activity and interaction with other children. These include swings, bicycles, wood horses 9. Games with rules: These are board games with rules found inside the box in general. To play with those games at least two people are required to follow the rules. However, rules can be simpli fi ed or new rules can be created to match the child s level of understanding.

45 Four Ways of Life for a Child with Autism 61 Four Ways of Life for a Child with Autism The child who lives in his own world The child who asks for others 1. Does not interact with his environment. 2. Does not understand yet that he can affect other people in his environment through sending a verbal or nonverbal message. 3. Despite the lack of communication, his body language can translate and explain his feeling. 1. Understands that his actions can affect his environment. 2. Takes other people s presence into consideration and asks for help. The child who communicates in a primitive way 1. Can interact in certain encouraging and enjoyable situations and ask for things important for him (such as his favorite toy or food). 2. Communicates with purpose however in a limited way, i.e., limited to asking others to do what he wants. 3. Can understand only simple and short sentences directed to him. The child who communicates with us 1. Can interact with people and use verbal language for communication. 2. Has no understanding of the communication rules especially in strange situations. 3. Relies on repeating other people s words or sentences when he cannot express himself in his own way.

46 Communication with the child who lives in his own world This child does not interact with his environment because he has not understood yet that he can affect other people in his environment through sending a verbal or nonverbal message. Draw the child s attention and push him to interact with you through social playing (Fig ) Make games interesting and encouraging: Draw his attention by tickling him, then putting him on your lap to play riding the horse. Join the child when he is playing alone. Call him to play a certain game by naming it with an encouraging rhythm and voice. Repeat the same games so that the child would get used to them and learn them. This way we can encourage the child to interact with the game. Explain everything that the child does unintentionally as a sign to communicate with you. If you were interested in all his actions and your reaction was positive, the child will be encouraged to repeat these actions. Create situations to push the child to communicate (Fig ) Keeping away or hiding the thing that the child wants. Close the toy box to stimulate him to ask for opening it. Stimulate the child to take roles through body signs, eye contact, easy songs, or when he badly wants something (Fig ) Give the child body signs to take his role. Help him physically to interact with you. Give him an example to imitate. Wait for the child and look at him to take his role. Slow the game down. Help the child understand words and expressions as much as possible (Fig ) Name things, people, actions, and situations so that he would start linking words to things. This way the child has an example to imitate. Show him examples of pictures of things you are talking about. Use the name of the child when talking to him instead of saying you this draws his attention and helps him learn his name. Use funny and interesting words. The child likes these words and learns them easily. Accompany what you say with signs and facial expressions to help him understand the words used. Diversify the games you play with the child: types of games include peekaboo, tickling, hide-and-seek, and the horse game (Fig ) Choose the toys in a suitable way: toys with cause and result, visual and environmental toys, building toys, sharing toys, creativity toys, symbolic toys, and physical games. Show the child that the game is interesting even if he is playing it wrong. It is more important for him to enjoy the game than to play it correctly. Help the child learn how to play simple games. Give him the opportunity to play in his own way and encourage him when he does something correctly. Help the child interact through sharing games such as the ball game. Imitate what the child does to draw his attention and continue the interaction. * If we had a plan for certain game and the child started to play in a different way, we should follow the child and his interests *Do not forget to talk to the child slowly and clearly

47 Four Ways of Life for a Child with Autism 63 Communication with the child who asks for others This child can understand that his actions can affect his environment. He takes our presence into consideration and asks for our help. Encourage the child to use new ways to ask for physical games such as tickling or hide-and-seek (Fig ) When the child gets used to a game, you can change it or change the way you play it by making mistakes on purpose. Create a routine that the child gets used to, then change it suddenly. Hide things in unusual places. Surprise him with touch and smell senses. Change the way the child asks to participate in a certain physical game. Help him communicate for new reasons (different from requests) within the usual games: Give him choices between different ways to take roles. Follow his interests when he takes a certain initiative. If the child does not like to change the way of playing, do not give up and wait for him to accept the change do not force the change. Help the child use the roles learned during games, songs, books, or activities. Help the child generalize. Some of the activities that encourage the child to communicate are the peekaboo and hide-and-seek games. Help the child develop or change his body communication (Fig ) Encourage him to use signs, pictures, sounds, or words. Put pictures next to the things they represent or in a small booklet to help him use them. Repeat signs and words according to the level of the child and play guessing games with him. Increase the situations that give the child the chance to ask for new things (Fig ) Put things he likes in places that cannot be reached. Give him what he wants step by step. Give him what he wants except for one thing. Help the child understand words and expressions as much as possible (Fig ) Same as this section in communication with the fi rst type Diversify the games you play with the child (Fig ) The games suggested in communication with the fi rst type can be used. Play differently within the same game. Encourage the child to imitate you during symbolic playing such as talking over the phone. Help him respond to your requests and directions. For example, put the apple in the plate. Encourage the child to generalize playing with other people such as the grandparents and siblings. This way he is encouraged to generalize what he learned by using the same way with other people from his environment.

48 64 2 Enhancing Childhood Development in Children with Autism Communication with the child who communicates in a primitive way This child can interact in certain enjoyable and encouraging situations and ask for things important for him (such as his favorite toy or food). He communicates on purpose but this communication remains limited to asking others to do what he wants. He can understand words directed to him if we use simple and short sentences. The child learns to take roles regularly with physical playing (Fig ) Give the child a verbal example about the expressions that he can use of words or simple sentences. This allows him to use these words and pictures through imitating and repeating what he hears. Give him signs so that he can understand that he has to repeat the example he is seeing or continue the expression we started with. Start with a sentence that he has to continue. Ask questions such as: open questions with choices, closed questions that can be answered by yes or no, questions that start with who or what. Encourage the child to take the initiative with physical playing instead of waiting for you to start the game (Fig ) Give him signs that help him take the initiative. Develop signs to reach communication by pictures. Develop communication by pictures to reach verbal communication. Develop words to reach sentences. Encourage him to help communicate in different situations (Fig ) Refuse and protest. Use greeting expressions. Draw your attention to a person or a thing. Comment on an unusual thing. Help the child understand words and sentences as much as possible and follow simple directions (Fig ) Use correct and simple sentences to help him hear the spoken language rules and use them later on. Name things, people, actions and situations the right way. Use the names of people after using pronouns. Help him understand that every word in the sentence has its own meaning and that words have connection in between them within the sentence. Diversify the games that you play with the child (Fig ) Beside the games proposed in the fi rst and second ways, symbolic games and games that have speci fi c rules can be used.

49 Communication with the child who communicates with us This child can interact with us and use verbal language as a way of communication, but he has not understood yet all the rules of communication especially in strange situations. He relies on repeating words or sentences when he cannot express using his own way. Help the child change his way of communication (Fig ) Exchange repeated words by special words for the child. When his ability to understand gets better, repeating the same words regresses. Use correct words and sentences during speech. Use pictures for subjects that the child cannot express verbally such as feelings. Help him communicate: The child can comment on what he sees, draw attention by calling or answering. Get him to apply what he learned with you or other people and in new situations. Help him communicate & talk about hypothetical situations (Fig ) Encourage him to answer questions that start with what, who, where, why, how. Use questions in simple songs, so he can get used to asking them. Show him pictures that have the answers and ask him to choose. Bene fi t from physical games such as hide-and-seek by repeating questions like where are you? The questions that start with why and how are the most dif fi cult. Make the questions understandable by giving him the answer and expect from him yes or no. Talk about the past and the future, about feelings. Play acting games with the roles of mother and father. Help the child make a conversation by teaching him (Fig ) How to start and end a conversation. How to stick to the conversation s subject. To understand that people do not always understand what he says and he has, in this case, to change the way he addresses others. To ask others to clarify what they are saying. To respect the conversation rules within social playing. Help him develop his ability to understand speech (Fig ) Break down long sentences. Stress on abstract words by accompanying them with signs & repeating them in different sentences. If you notice that the child does not understand the words addressed to him because he repeats what was said without changing anything in the sentence, you can simplify the sentence to make it understandable. Repeat what the child says in a right way to correct the mistakes he committed without asking him to repeat what he said. While talking with child, address abstract issues such as how he behaves and how to overcome obstacles. Help him communicate in an effective way with other children (Fig ) Teach the child how to start a game with another child. Teach the child how to stay within the game, so that he can respect its rules with other children. Later, he can generalize it with others. Teach the child how to end the game by using certain expressions.

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